Illness Management: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills illness management in order to:
- Identify client data that needs to be reported immediately
- Apply knowledge of client pathophysiology to illness management
- Educate client regarding an acute or chronic condition
- Educate client about managing illness (e.g., acquired immune deficiency syndrome [AIDS], chronic illnesses)
- Implement interventions to manage the client's recovery from an illness
- Perform gastric lavage
- Promote and provide continuity of care in illness management activities (e.g., cast placement)
- Manage the care of a client with impaired ventilation/oxygenation
- Evaluate the effectiveness of the treatment regimen for a client with an acute or chronic diagnosis
Client data that must be immediately reported to the nursing supervisor and/or the physician, stated simply, include data that indicates that one or more of the basic and essential problems and needs, significant and substantial changes in the client's status, and all unexpected outcomes and responses, including adverse events and adverse reactions to the care and treatments that were rendered to the client.
As previously detailed in the section entitled "Setting and Establishing Client Priorities", the most basic and essential problems and needs of our clients include those in the ABCs, that is the airway, breathing and cardiovascular status, the priority needs as described by Maslow which are the physiological needs, the needs of the clients in terms of safety and the psychological needs, the need for belonging and love, the needs for esteem by others and self-esteem, and the need of the clients for self-actualization, in terms of descending order of priority, and lastly, the elements of MAUUAR which are the ABCs and then the mental status, the presence of acute pain, acute urinary elimination problem, untreated problems, abnormal diagnostic data including laboratory data, and client risks including the risk for skin breakdown and the risk for infection or falls.
Significant changes, simply defined, are client changes that are significantly different from the client's baseline and/or are not normal and not consistent with the client's pattern. For example, a significant change in the client's vital signs after an invasive procedure as compared and contrasted to the pre procedure vital signs requires that the nurse report this significant change and other pertinent data to the physician.
Simply defined, unexpected responses to care and treatments include all outcomes that are unexpected and not therapeutic. For example, a client who experiences an idiosyncratic response or an adverse reaction to a medication is having an unexpected response to a treatment; and a client who does not have a therapeutic response to chest tube drainage or mechanical ventilation is also having an unexpected response to these treatments and care. As stated, these unexpected responses, in addition to significant client changes, must be reported immediately, particularly when these events affect a priority client need like oxygenation and cardiovascular status.
Nurses apply their indepth knowledge of client pathophysiology to illness management as they care for groups of clients. Examples of this application of this knowledge of client pathophysiology include the risk factors, etiology, signs, symptoms, complications and how to prevent them using the principles of pathophysiology, side effects and adverse reactions to illness management.
Examples of this application of knowledge were previously discussed in these previous sections of this NCLEX RN review entitled:
- Applying a Knowledge of Pathophysiology to the Monitoring for Complications
- Applying a Knowledge of Pathophysiology When Establishing Priorities for Interventions with Multiple Clients
- Applying a Knowledge of Client Pathophysiology to Home Safety Interventions
- Applying a Knowledge of Pathophysiology to Health Screening
- Applying a Knowledge of Pathophysiology to Non-Pharmacological Comfort/Palliative Care Interventions
- Applying a Knowledge of the Client's Pathophysiology to Rest and Sleep Interventions
- Applying a Knowledge of Client Pathophysiology When Measuring Vital Signs
- Applying a Knowledge of Nursing Procedures, Pathophysiology and Psychomotor Skills When Caring for a Client with an Alteration in Body Systems
- Applying a Knowledge of Client Pathophysiology to Illness Management
As stated previously, the ultimate and primary goal of client education is to enable the client to change in some aspect of their health wellness and illness. Education promotes the client's ability to make knowledgeable decisions about the care, treatments and interventions that they choose to have and choose to not have.
Nurses assess the educational needs of their clients, they analyze this assessment data, they diagnose the learning needs of their clients in terms of their knowledge or skills deficits, and then they plan educational activities that meet their knowledge and skills needs that are consistent with the client's level of understanding and other factors such as their level of motivation, their level of cognition and their learning style preferences.
Educational activities are then implemented for the client and family members or groups of clients that are tailored to meet the client's pre-established learning goals.
Some of the content that is typically included in the patient teaching plan relating to both acute and chronic health concerns and disorders include information about:
- The pathophysiology of the health related concern, disease, condition, and/or illness
- The risk factors associated with the health related concern, disease, condition, and/or illness
- The modifiable risk factors, such as dietary modifications, medication adherence and exercise, that can be changed to improve one's state of heath and to decrease the risks associated with the disease and its possible complications
- The non modifiable risk factors that cannot be changed, but however, may be able to be compensated for with some client actions and changes in term of their behavior
- The procedures, such as diagnostic tests, that will be used to diagnose and also be used for the ongoing monitoring of the client with an acute or chronic disease
- The signs and symptoms of the acute or chronic disorder, ways to symptomatically treat treatable signs and symptoms and what signs and symptoms should be reported to the client's doctor
- All of the treatments and interventions, including medications, that the client will and may receive. This information should include all of the educational components necessary for informed consent including the benefits and risks associated with these interventions, possible alternatives to the intervention or procedure, and the risks and benefits associated with these alternative interventions.
- Self care strategies for the client
- The available community resources, including financial resources, that can assist the client with coping with and recovering from a chronic or acute condition or disorder
- The frequency of follow up care in the community and the need for follow up care
In addition to all of the education that should be provided to clients with an acute or chronic as discussed immediately above in the section entitled "Educating the Client Regarding an Acute or Chronic Condition and Illnesses", some illnesses, diseases and disorders such as serious, chronic and terminal Illnesses such as cancer and Lou Gehrig's disease as well as those that require life long treatment like acquired immune deficiency syndrome (AIDS) require special educational considerations and interventions.
For example, clients affected with AIDS need special education in terms of the importance of continuing medications on a consistent basis every day without fail; and they also need special education on how to prevent the spread of their infection to others in the home and with sexual partners.
Clients with terminal diseases not only need education as discussed above in the section entitled "Educating the Client Regarding an Acute or Chronic Condition and Illnesses", they also need education related to end of life choices in terms of hospice and palliative care, advance directives, post death planning, living wills, durable powers of attorney and other issues.
As discussed in the previous section entitled "Promoting Client Progress Toward Recovery From an Alteration in Body Systems", recovery from an illness is a function of both intrinsic and extrinsic factors and forces.
These factors and forces were organized into the framework associated with the Dimensions of Health model which is helpful to apply to the client's recovery. Examples of these dimensions and their applications to the client's recovery from an illness were discussed in this same section of this review and these dimensions include:
- The Biological Dimension of Health
- The Psychological Dimension of Health
- The Environmental Dimension of Health
- The Behavioral Dimension of Health
- The Sociocultural Dimension of Health
- The Health Systems Dimension of Health
Gastric lavage is indicated for a number of disorders including poisonings, drug overdoses and gastrointestinal bleeding which is often controlled with iced lavage.
This medically aseptic procedure is done in the following manner for inserting a gastrointestinal tube that will be done for the insertion of this tube after checking the doctor's order, validating the identification of the client and explaining the procedure to the client is:
- Place the client in a high Fowler's position whenever possible
- Inspect the nares and select the best one to use that is not obstructed with a deviated septum or another narrowing
- Measure the length of the nasogastric tube from the nose to the ear lobe to the tip of the xiphoid. This point should be the length that is needed to enter the stomach Mark this point with tape on the nasogastric tube.
- Apply a bit of water soluble jelly and a local anesthetic to the tip of the tube.
- Have the client to look up so that their neck is hyperextended upward.
- Advance the nasogastric tube until you get some resistance at the nasopharynx.
- Continue to advance the tube below the curve of the nasopharynx as the client now takes small sips of water if they are able to do so while they are leaning forward.
- Check for the correct placement of the nasogastric tube.
- Secure the nasogastric tube to the nose with tape.
- Secure the tubing to the client's gown with a safety pin.
- Clamp the tube or connect it to the suction device if ordered.
Lavage is then done according to the doctor's order after the correct placement of the gastrointestinal tube in the stomach is confirmed. This procedure is somewhat similar to that of irrigating a nasogastric tube with the exception of connecting the tube to suction and the type of solution that is used.
The procedure for gastric lavage is listed below:
- Instill the ordered solution
- Clamp the tube off to retain the ordered solution(s).
As previously discussed immediately above in the sections entitled "Educating the Client about Managing Illnesses” and "Educating the Client Regarding an Acute or Chronic Condition and Illnesses", as well as the section entitled "Continuity of Care" much earlier in this NCLEX RN review, nurses facilitate, manage and coordinate the care of the client along the continuum of care in a seamless, unfragmented, effective and efficient manner according to the client's ongoing and changing needs.
Many continuity of care activities include the provision of patient and family education, follow up care with the client's primary care doctor and any specialists that they may need, and other community resources in terms of restorative and rehabilitation care such as a physical therapist, an occupational therapist and/or a speech therapist, assistance such as Meals on Wheels, transportation to and from medical care settings, and ongoing reassessments of the client to determine whether or not the treatment goals and the client expected outcomes have been met.
Emergency care clients also need the support of the nurse in terms of promoting and providing the continuity of care for relatively simple procedures such as casting a fractured extremity. The client must be educated about the signs and symptoms of compartment syndrome which include intense pain that cannot be relieved with raising the affected limb and/or the client's ordered analgesic medications, burning pain, paresthesia, hypoesthesia, pulselessness, and cool and pale skin; and they must also be educated about how to prevent compartment syndrome, how to identify the signs and symptoms of compartment syndrome, and when to call their doctor in the community with these and other symptoms.
In addition to assessing the client's arterial blood gases and the client's symptoms of impaired ventilation and oxygenation, there are other tests such as pulmonary function tests that provide data related to the client's respiratory functioning.
The normal arterial blood gases are:
- Oxygen saturation (SaO2): 94 – 100%
- Partial pressure of oxygen (PaO2): 75 – 100 mmHg
- Partial pressure of carbon dioxide (PaCO2): 38 – 42 mmHg
- Bicarbonate – (HCO3): 22 – 28 mEq/L
- Arterial blood pH: 7.38 – 7.42
Pulmonary function tests, often done by a certified respiratory therapists or pulmonologist, consist of an array of diagnostic tests and measurements including:
- Pulse oximetry: Pulse oximetery measures the oxygen saturation of arterial blood by using a sensor on a client's finger or, when necessary, on their forehead, nose, or ear. In addition to the certified respiratory therapist's measuring pulse oximetry, this measurement is and can be measured by nurses and specially trained unlicensed assistive personnel such as nursing assistants at the bedside. The normal value for the oxygen saturation of arterial blood should be from 94 to 100%.
- Spirometry: Some of the data that can be obtained with diagnostic spirometry testing include tidal volume, forced vital capacity, non forced vital capacity, maximum inspiratory pressure, maximum expiratory pressure, lung capacity, lung volumes other than residual lung volumes and other measures of pulmonary functioning.
- Tidal Volume: Tidal volume is the volume of air in terms of mLs that is normally inhaled and exhaled during the client's normal respiratory cycle including their inhalation and exhalation without the any exertion on the part of the client and without any obstructive force. The normal tidal volume of adults is typically about 500 mL and, mathematically, the normal can be determined mathematically for non-adult clients by knowing that the normal tidal volume should be 7 mLs per kilogram of body weight.
- Maximum Expiratory Pressure: Maximal expiratory pressure, or MEP, is impacted by the client's strength of their accessory muscles of breathing during expiration, the strength of the client's diaphragmatic muscles, the client's lung volume during occlusion, the length of time that the airway is occluded, and the client's ventilatory drive and efforts. The MEP, like the maximum inspiratory pressure, can normally decrease as the result of the aging process and it can also vary according to gender. The normal maximum expiratory pressure is more than 95 cm H2O among the members of the female population and more than 140 cm H2O for males.
- Maximum Inspiratory Pressure: Maximal inspiratory pressure, or MIP, which is also referred to as negative inspiratory force, is similar to the MEP and it is the amout of pressure that the client can exert against an occlusion. Again, the MIP can vary with age and gender. Those with an MIP of less than – 20 cm H2O have moderate to severe respiratory problems. The lowest acceptable limit for males is – 75 cm H2O and the lowest acceptable limit for females is – 50 cm H2O. The client's maximal inspiratory pressure is a function of the client's strength of their accessory muscles of respiration during inspiration, the strength of the client's diaphragmatic muscles, the client's lung volume during occlusion, the length of time that the airway is occluded, and the client's ventilatory drive and efforts.
- Lung Compliance: Pulmonary compliance or lung compliance is a function of the lung's elasticity and the pulmonary volume. Pulmonary compliance is low when the lungs are stiff, without their normal degree of elasticity and without good recoil; the lungs are somewhat stiff. Low lung compliance can affect clients of all ages with different respiratory disorders and diseases. For example, the neonate may have low lung compliance because they do not have sufficient lung surfactant or atelectasis, and pediatric as well as adult clients can have low lung compliance because they are adversely affected with asthma, a pneumothorax, pulmonary fibrosis, pneumonia, and edema, among other disorders. The normal lung compliance among adults is approximately from 100 to 200 mL/c of water.
- Airway Resistance: Airway resistance measurements reflect the airways' resistance to and opposition to the normal flow of air through the bronchopulmonary system.
- Forced Vital Capacity: Forced vital capacity reflects the measurement of the client's volume of air that they can expel against resistance. Forced vital capacity reflects the strength of the client's muscles of respiration.
- Forced Expiratory Volume: Also measured with spirometry, forced expiratory volume consists of lung's ability to exhale forcibly for a one second.
- Diffusion Capacity: The normal level of DLCO, or diffusion capacity, is about 25 mL/min/mm Hg. The diffusion capacity is altered and decreased when the client is adversely affected with chronic obstructive pulmonary disease and respiratory fibrosis and, in rare situations, it can be increased with polycythemia and its abnormally high level of body oxygenating red blood cells.
- I:E Ratio: The I:E ratio is the ratio of the client's duration of inspiration and the client's duration of expiration. The normal I:E ratio is 1:2; this ratio becomes greater, such as 1:3, when the client is affected with an air flow that is not sufficient or it is obstructed as is the case with respiratory disorders such as asthma, chronic bronchitis, and emphysema. At times the client can be symptomatic as the result of an abnormal I:E ratio and at other times the client can present with Kussmaul's, Biot's and/or Cheyne-Stokes respiratory patterns.
- Minute Volume: Minute volume is the amount of air that the client exhales or inhales in one minute, which is referred to as the expired minute volume and inhaled minute volume, respectively.
- Expiratory Reserve Volume: Expiratory reserve volume is the greatest volume of air that can be exhaled after the end expiratory phase of the client's respiratory cycle.
- Inspiratory Reserve Volume: Inspiratory reserve volume is the greatest volume of air that can be inhaled at the end of the inspiratory phase of the client's respiratory cycle.
- Residual Volume: Residual volume is the volume of air that is left as residual in the lungs after the client has exercised a forceful and maximal exhalation.
- Exercise Testing: The Exercise Induced Bronchoconstriction Test: The most commonly employed forms of diagnostic cardiopulmonary exercise testing Include exercise induced bronchoconstriction testing, full cardiopulmonary exercise testing and the Six Minute Walk test . Exercise induced bronchoconstriction tests consist of measuring the forced expiratory volume in one second (FEV1) and the forced vital capacity (FVC) prior to exercise, 5 minutes after the client began to exercise and ½ hour after exercise on a treadmill while the pulse rate is 80% of its predicted maximum rate. Bronchoconstriction is suspected when the results show a drop in the FEV1 or the FVC of more than 15% during this test.
- Exercise Testing: Full Cardiopulmonary Exercise Testing: Full and complete cardiopulmonary exercise testing is done to collect assessment data related to the person's air flow, cardiac rate, arterial blood gases, oxygen consumption, and carbon dioxide production when the client is resting as well as when they are exercising on a treadmill, as discussed immediately above. The aim of this test is to determine and differentiate between the client's maximal exercise capacity and their reduced exercise cardiopulmonary status.
- Exercise Testing: The Six-Minute Walk Test: This diagnostic test measures the ability of the client to walk at their own rate for six minutes in terms of their respiratory data.
In addition to the nurse assessing the client's signs and symptoms of respiratory disorders, the nurse also considers all of the pertinent respiratory data that are collected by others, as described above, and then the nurse plans care and monitoring accordingly.
Depending on the medical diagnoses, the medical doctors' orders and the nursing diagnoses in addition to the scopes of practice, roles and responsibilities of the other members of the health care team such as the physicians, the physician assistants, the nurse practitioner, the certified respiratory therapist and the nurse, complete care and follow up care of the client is provided by the health care team.
Evaluating the Effectiveness of the Treatment Regimen for a Client with an Acute or Chronic Diagnosis
As with all other nursing care, nurses evaluate the effectiveness of the client's treatment regimen when they have an acute or chronic diagnosis and health care problem. This evaluation, a phase of the nursing process, measures whether or not the client is meeting the expected outcomes of the care provided in terms of the client's achievement of their planned goals.
- Alterations in Body Systems
- Fluid and Electrolyte Imbalances
- Illness Management (Currently here)
- Medical Emergencies
- Unexpected Responses to Therapies